The stigma of mental illness: patients' anticipations and experiences

BACKGROUND: There are studies that either deal with the stigmatization patients anticipate or with patients' concrete stigmatization experiences. Up until now, however, research is short of studies that investigate both aspects of subjective stigmatization simultaneously. AIMS: This study aims at investigating to what extent patients with schizophrenia or depression anticipate and experience stigmatization and how this is influenced by the type of mental disorder and the social environment. METHOD: A total of 210 patients with schizophrenia or a depressive episode were interviewed, one half living in a city and the other in a small town. RESULTS: Most of the patients expect negative reactions from the environment, particularly as concerns the access to work. Concrete stigmatization experiences were most frequently reported in the domain of interpersonal interaction. Even though schizophrenia patients and patients with depression anticipated stigmatization similarly frequently, the former reported concrete stigmatization experiences more frequently than the latter. Conversely, patients living in a small town anticipated stigmatization more frequently than patients from the city, even though both had actually experienced stigmatization at a similar rate. CONCLUSION: The results underline the necessity to differentiate between anticipated and experienced stigmatization. This is highly relevant for planning interventions aimed at reducing the stigma of mental disorder.     

Eugenics, genetics, and mental illness stigma in Chinese Americans

Background  

The increasing interest in the genetic causes of mental disorders may exacerbate existing stigma if negative beliefs about a genetic illness are generally accepted. China’s history of policy-level eugenics and genetic discrimination in the workplace suggests that Chinese communities will view genetic mental illness less favorably than mental illness with non-genetic causes. The aim of this study is to identify differences between Chinese Americans and European Americans in eugenic beliefs and stigma toward people with genetic mental illness.     

Structural levels of mental illness stigma and discrimination

Most of the models that currently describe processes related to mental illness stigma are based on individual-level psychological paradigms. In this article, using a sociological paradigm, we apply the concepts of structural discrimination to broaden our understanding of stigmatizing processes directed at people with mental illness. Structural, or institutional, discrimination includes the policies of private and governmental institutions that intentionally restrict the opportunities of people with mental illness. It also includes major institutions' policies that are not intended to discriminate but whose consequences nevertheless hinder the options of people with mental illness. After more fully defining intentional and unintentional forms of structural discrimination, we provide current examples of each. Then we discuss the implications of structural models for advancing our understanding of mental illness stigma, including the methodological challenges posed by this paradigm.     

Implications of educating the public on mental illness, violence, and stigma

This study examined how two types of public education programs influenced how the public perceived persons with mental illness, their potential for violence, and the stigma of mental illness. A total of 161 participants were randomly assigned to one of three programs: one that aimed to combat stigma, one that highlighted the association between violence and psychiatric disorders, and a control group. Participants who completed the education-about-violence program were significantly more likely to report attitudes related to fear and dangerousness, to endorse services that coerced persons into treatment and treated them in segregated areas, to avoid persons with mental illness in social situations, and to be reluctant to help persons with mental illness.     

Implicit and explicit stigma of mental illness: links to clinical care

This study examined implicit and explicit measures of bias toward mental illness among people with different levels of mental health training, and investigated the influence of stigma on clinically-relevant decision-making. Participants (N = 1539) comprised of (1) mental health professionals and clinical graduate students, (2) other health care/social services specialists, (3) undergraduate students, and (4) the general public self-reported their attitudes toward people with mental illness, and completed implicit measures to assess mental illness evaluations that exist outside of awareness or control. In addition, participants predicted patient prognoses and assigned diagnoses after clinical vignettes. Compared with people without mental health training, individuals with mental health training demonstrated more positive implicit and explicit evaluations of people with mental illness. Further, explicit (but not implicit) biases predicted more negative patient prognoses, but implicit (and not explicit) biases predicted over-diagnosis, underscoring the value of using both implicit and explicit measures.     

The stigma of mental illness in Germany: a trend analysis

BACKGROUND: While there are some indications that the mental health literacy of the public has improved within recent years, the findings concerning its attitudes towards the mentally ill are quite inconsistent. AIMS: The aim of this study is to examine whether any changes have taken place in Germany over the last decade regarding the stigmatisation of mentally ill people. METHOD: In 2001, a representative population survey was carried out among the German adult population, using the same sampling procedure and the same measure for the assessment of perceived stigma as in a previous survey that had been conducted in 1990. RESULTS: Our findings suggest that in 2001, the German public was somewhat less inclined to believe that former mental patients are exposed to stigmatisation than a decade ago. While this holds especially true for the devaluation of patients, the picture is more mixed for discrimination. The trend towards less perceived stigmatisation is particularly pronounced among people who are familiar with psychiatric treatment. CONCLUSIONS: Since a substantial amount of perceived stigma still persists, further efforts to reduce the stigma attached to mental illness are needed.     

Effects of age, gender, and causality on perceptions of persons with mental retardation

The present study examined the effects of age, gender, and causality on the perceptions of persons with mental retardation. Participants rated individuals with mental retardation using a semantic differential scale with three factors: activity, evaluation, and potency. Target individuals in each scenario varied on the variables of age (8, 20, 45), gender (male, female), and causality of mental retardation (genetic, self-inflicted, inflicted by others). Perceptions differed significantly according to causality, with those with mental retardation due to inheritance/genetics (Down Syndrome) evaluated most positively and those whose mental retardation was self-inflicted viewed most negatively (brain damage due to drinking cleaning fluid). Female participants gave higher ratings than male participants for target subjects on evaluation and potency factors. Implications of findings for persons with mental retardation are discussed.     

Considering context, place and culture: the National Latino and Asian American Study

This paper provides a rationale for, and overview of, procedures used to develop the National Latino and Asian American Study (NLAAS). The NLAAS is nationally representative community household survey that estimates the prevalence of mental disorders and rates of mental health service utilization by Latinos and Asian Americans in the US. The central aims of the NLAAS are to: 1) describe the lifetime and 12-month prevalence of psychiatric disorders and the rates of mental health services use for Latino and Asian American populations using nationwide representative samples of Latinos and Asian Americans, 2) assess the associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and utilization rates of mental health services, and 3) compare the lifetime and 12-month prevalence of psychiatric disorders, and utilization of mental health services of Latinos and Asian Americans with national representative samples of non-Latino whites (from the National Comorbidity Study-Replication) (NCS-R) and African Americans (from the National Survey of American Life) (NSAL). This paper presents new concepts and methods utilized in the development of the NLAAS to capture and investigate ethnic, cultural and environmental considerations that are often ignored in mental health research.     

Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada

Background  Health services in Canada are publicly funded. However, the use of health services, especially mental health services, by ethnic minority groups in Canada, has not been well studied. Objectives  The objectives of the study were to estimate the 12-month prevalence of mental health service use by ethnicities, overall and among those with major depression, and to identify factors associated with mental health services use in different ethnic groups in Canada. Methods  Data from the Canadian Community Health Survey (CCHS-1.1) were used. Participants included in this analysis were white who were born in Canada (n = 108,192), white immigrants (n = 10,892), Chinese (n = 1,785), South Asian (n = 1,214), and South East Asian immigrants (n = 818). Participants were selected using multiple staged, stratified random sampling procedures from household residents aged 12 years or older in ten provinces. Results  White people were more likely to have used mental health services than Chinese participants and those from South Asian and South East Asian regions. The Chinese participants appeared to be less likely to have used mental health services than those in the South Asian and South East Asian groups, in those without major depression. Conclusions  In Canada, Asian immigrants are less likely to use mental health service use than white people. More studies are needed to examine factors affecting mental health service use in Asian immigrants living in North America. JianLi Wang is supported by a New Investigator Award from the Canadian Institutes of Health Research.     

Internalized stigma of mental illness: psychometric properties of a new measure

The study evaluated the Internalized Stigma of Mental Illness (ISMI) scale, designed to measure the subjective experience of stigma, with subscales measuring Alienation, Stereotype Endorsement, Perceived Discrimination, Social Withdrawal and Stigma Resistance. The ISMI was developed in collaboration with people with mental illnesses and contains 29 Likert items. The validation sample included 127 mental health outpatients. Results showed that the ISMI had high internal consistency and test-retest reliability. Construct validity was supported by comparisons against scales measuring related constructs with the same methodology. As expected, the ISMI had positive correlations with measures of stigma beliefs and depressive symptoms, and it had negative correlations with measures of self-esteem, empowerment and recovery orientation. Factor analyses of the joint set of items from the ISMI and each scale supported the distinction between constructs. Having a validated measure of internalized stigma may encourage clinicians to include stigma reduction as a verifiable treatment goal in addition to symptom reduction.     

Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma -- protest, education, and contact -- and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.     

How adolescents perceive the stigma of mental illness and alcohol abuse

OBJECTIVES: Research among adults has yielded three sets of conclusions about the stigma of mental illness. First, people with mental illness are stigmatized more severely than those with physical health conditions; those who abuse alcohol are viewed more harshly than those with mental illness. Second, stereotypes of mental illness related to responsibility and dangerousness lead to negative emotional reactions and discriminatory behaviors. Third, familiarity with people with mental illness tends to diminish stigma. This study attempted to validate these findings with a large and diverse sample of adolescents. METHODS: A total of 303 adolescents completed a revised version of the Attribution Questionnaire (rAQ) that presented four vignettes, each describing a different type of peer: a peer with mental illness, with mental illness caused by a brain tumor, with alcohol abuse problems, and with leukemia. The rAQ comprises seven Likert scale items of agreement that research participants rated for each vignette. Items included pity, danger, fear, responsibility, anger, help, and avoidance. Participants also completed a revised Level of Contact Report to assess their familiarity with mental illness. RESULTS: As with adults, adolescents stigmatized peers who abuse alcohol most severely, followed by those with mental illness. Peers with leukemia were treated more benignly than the other groups. Having a brain tumor mediated the stigmatizing effect of mental illness. Adolescents who agreed that persons with mental illness are responsible for their illness and are dangerous demonstrated more discrimination toward these persons. However, this finding was not supported for alcohol abuse. Familiarity yielded an unexpected effect among adolescents; those who reported more familiarity with mental illness were more likely to endorse stigma of mental illness. CONCLUSIONS: Adolescents tended to discriminate among conditions, viewing substance abuse more harshly than the other disorders. Blame and dangerousness were important variables leading to discrimination, and contact with persons with mental illness led to more discrimination.     

Differential referral patterns to ethnic-specific and mainstream mental health programs for four Asian American groups

This study examined the referral patterns of Chinese, Japanese, Filipino, and Korean Americans at ethnic-specific versus mainstream programs in a public mental health system. As predicted, social/ community-based services and family/friends to a lesser degree referred each Asian American group to ethnic-specific programs more than other referral sources (e.g., criminal justice and health services). Referrals by social/community-based programs to ethnic-specific versus mainstream programs were the most significant for Chinese Americans, followed by Japanese and Filipino Americans, and the least significant for Korean Americans. These findings suggest Asian American clients themselves and their social networks may view ethnic-specific programs as more culturally responsive than mainstream programs.     

Does mental illness stigma contribute to adolescent standardized patients' discomfort with simulations of mental illness and adverse psychosocial experiences?

OBJECTIVE: Adolescent mental illness stigma-related factors may contribute to adolescent standardized patients' (ASP) discomfort with simulations of psychiatric conditions/adverse psychosocial experiences. Paradoxically, however, ASP involvement may provide a stigma-reduction strategy. This article reports an investigation of this hypothetical association between simulation discomfort and mental illness stigma. METHODS: ASPs were randomly assigned to one of two simulation conditions: one was associated with mental illness stigma and one was not. ASP training methods included carefully written case simulations, educational materials, and active teaching methods. After training, ASPs completed the adapted Project Role Questionnaire to rate anticipated role discomfort with hypothetical adolescent psychiatric conditions/adverse psychosocial experiences and to respond to open-ended questions regarding this discomfort. A mixed design ANOVA was used to compare comfort levels across simulation conditions. Narrative responses to an open-ended question were reviewed for relevant themes. RESULTS: Twenty-four ASPs participated. A significant effect of simulation was observed, indicating that ASPs participating in the simulation associated with mental illness stigma anticipated greater comfort with portraying subsequent stigma-associated roles than did ASPs in the simulation not associated with stigma. ASPs' narrative responses regarding their reasons for anticipating discomfort focused upon the role of knowledge-related factors. CONCLUSION: ASPs' work with a psychiatric case simulation was associated with greater anticipated comfort with hypothetical simulations of psychiatric/adverse psychosocial conditions in comparison to ASPs lacking a similar work experience. The ASPs provided explanations for this anticipated discomfort that were suggestive of stigma-related knowledge factors. This preliminary research suggests an association between ASP anticipated role discomfort and mental illness stigma, and that ASP work may contribute to stigma reduction.